12VAC35-105-20- under the guidance for Level III Serious Incidents involving sexual assault it states:  

"If the alleged sexual assault does not occur in the provision of a service or on the provider’s premises, reporting of the alleged sexual assault to DBHDS is required only if the adult with capacity gives consent for the report to be made."

Is there an expectation by the department to ask the individual to consent to CHRIS reporting if that individual is an adult with capacity and they disclose a sexual assault to a mental health clinician, case manager, etc. that did not occur on the premises of the provider or during the provision of a service? 

Under the same guidance for Level III Serious Incidents involving suicide attempts that result in hospitalization it states:

"Self-injurious behavior without the intent to die that results in a hospital admission or emergency room visit does not need to be reported as a Level III serious incident by all providers. However, the incident must be reported as a Level II serious incident by a provider if the incident occurred within the provision of their services or on their property."

This implies that all instances of self-injury require CHRIS reporting if it occurs on the premises of the provider or during the provision of a service.  It would be understandable to report self-injury if it results in a serious injury, but this language would include a multitude of minor self-inflicted injuries that would not meet the regulatory definition of a serious injury.  Please clarify as the language in its current form would necessitate many more CHRIS reports than what is likely being reported.

12VAC35-105-160 E- Providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider's premises.  However, the proposed guidance document under 12VAC35-105-160 E(1) states:

"In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider."

I think this was just an oversight but I wanted to make sure.  A provider would include this information in a CHRIS report, but not a Root Cause Analysis, because the Root Cause Analysis would not be required for a Level III incident that did not occur during the provision of a service or on the provider's premises.  

In addition, the very last page within the Guidance box states:

"The provider’s serious incident management policy should address how the provider will:
*  Collect, maintain, and review Level I serious incidents at least quarterly;"

Considering the newest regulation requires that providers collect/maintain/review all levels of serious incidents, would it be more helpful if this section of the guidance reflected "all serious incidents," to ensure there are no questions about which incident levels have quarterly reviews?

Finally, there are several references to an individual "only receiving licensed emergency services," but it is unclear for a CSB setting if this means the individual's only connection to the provider is through that emergency services program or if this means that the individual could be admitted to other services (like psychosocial rehabilitation or case management) but during the time of the incident, they are only receiving emergency services and those other service providers were not otherwise involved.  Please clarify.